The most common cause of runner's knee isn't just running

Preparations for that marathon, fun run or road race are likely getting underway, but don't exclude yourself from potential injury just because you may crossing the finish line on wheels. Cycling is as much to blame for so-called Runner's Knee - a painful inflammation that occurs on the outside of the knee.

"The people who tend to get it the most are those who have just changed their exercise regime. Say if a regular runner has started training for a marathon and has suddenly increased their mileage, that seems to set it off," said Dr Tyson Doneley, a hip and knee orthopaedic surgeon from Brisbane.

Bend and strain

Also known as iliotibial band (ITB) friction syndrome, it is related to repetitive bending and straining of the knee. This causes inflammation deep within the tight, fibrous structure (the ITB) that runs down the outer aspect of the thigh – from up near the hip, down to just beyond the knee.

That tight band of tissue rubs back and forwards over the prominent bony ridge that sits on the outside of the knee. The knee straightens and bends and after enough times, as the name implies, the friction or the rubbing causes inflammation, and pain.

It occurs more in those undertaking longer duration outdoors activities such as cycling, hiking and long-distance running, rather than being caused by shorter bursts of activity associated with the use of gym equipment or activities like crossfit.

"Runners are the main people who have it because they have their knee out straighter, but cyclists have the right angle too," explains Dr Doneley.

"The explosiveness or acceleration of the force doesn't correlate, the power of the stroke on a pedal doesn't tend to have a huge impact on it either. The main thing is the position of the knee.

"It happens mostly when the knee is bent 20 to 30 degrees. People who shuffle when they run tend to suffer from it more then those who do track work or interval sprints. Sprinting brings the knees into greater degrees of bend and this tends to protect against the problem," he said.

Pain in the leg?

It can start as being troublesome at the end of a run to being debilitating and pain that is present even when at rest.


When Runner's Knee first starts to present, people will notice it towards the end of an activity, and then when they stop and cool down the pain will go away. The next stage is when people notice it earlier in their activity, but the symptoms stop when they cool down. Finally, the pain can progress to being present all of the time.

Other physical conditions can set it off such as people who have bowing of their legs or flat-footed, as it increases the straining on the outside of the leg when the foot is placed on the ground. Those with weak core musculature can also experience this same strain.

"Treatment means getting patients to reduce their exercise regime. Usually by avoiding the activity that set it off over a period of about six to eight weeks, we will see a resolution," said Dr Doneley.

"That gets combined with a stretching regime, designed to stretch the structures on the outer aspect of the leg – in particular the iliotibial band. Strengthening the abdominal core and gluteal muscles is also important at this stage in order to stabilise the pelvis during the foot-strike whilst running."

What a relief

Pain relief comes with activity avoidance, along with other proven strategies, said Dr Doneley.

"First line treatment would involve the use of foam rollers on the outside of the leg for myofascial releasing of the muscles. We'd also recommend topical anti-inflammatory gels, anti-inflammatory medications, the use of ice to help manage symptoms in the first stage."

After this, specialists would try ultrasound-guided steroid injections into the painful areas, but this would not be a common procedure and would only be attempted after everything else had been tried.

There are also surgical releases of the tissue as absolute end-stage treatment for conditions that have been refractory to any other treatment. Dr Doneley said this is an exceedingly rare procedure, as the non-operative strategies have been shown to be highly successful. Regardless of the discipline, surgery is always approached with caution, given the risks involved in producing scar tissue and other damage.

"Runner's Knee a really common diagnosis made by a physiotherapist, and most patients will spend more time with a physio for treatment. Even if someone comes into an orthopaedist's office for treatment, we will try to employ that physio type of treatment."

Mix things up

To avoid the condition sneaking up, Dr Doneley says people need to get a stable base of fitness before increasing their mileage. He recommends incrementally increasing training distances.

"People should avoid 'shuffling' when they run. Interval training, with alternating speeds rather than long slow runs are better. Running down hills in particular tend to set this off – so using flatter terrain. Flat-footed people can use orthotics or shoe inserts to help change the shape of the foot," he said.

Cyclists are also prone to Runner's Knee, and they have some tricks at their disposal to help prevent the condition. In order to avoid the knee being positioned at 20 to 30 degrees the seat can be lowered, as well as the positioning of the handlebars, pedals and cleats all adjusted to get the correct angle.  

For more information visit HealthShare, a joint venture with Fairfax to improve the health of regional Australians. Or you can find a specialist near you using the health tool below.